Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 26 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
3G
0H
0I
Potential for more than minimal harm
18D
3E
1F
Potential for minimal harm
0A
0B
0C
June 4, 2026Standard inspection, Complaint inspection · 13 citations
- G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Specifically, for 4 of 36 sampled residents, a resident's skin condition was not evaluated and treated, a resident had wound care provided without orders, a resident was hospitalized and no documentation was found of the resident's change in condition, and a resident expired at the facility and no documentation could be found of the resident's change in condition. Resident identifiers: 9, 59, 61, and 62.
- G
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview, and record review, for 2 of 36 sampled residents, the facility did not provide each resident assisted nutrition to maintain acceptable parameters of nutritional status. In addition, a resident was not offered a therapeutic diet when there was a nutritional problem. Specifically, a resident who was provided a tube feeding lost a significant amount of weight when the tube feeding was discontinued for 5 days and her oral intake was not meeting her nutritional needs. This example will be cited as a harm. In addition, a resident with a high potassium was not provided low potassium foods when the dialysis center ordered it. Resident identifiers: 6 and 13.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation and interview it was determined that the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the dishmachine temperatures were below the required manufacture temperatures for sanitizing dishes.
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on interview and record review, for 3 of 36 sampled residents, the facility did not provide routine and emergency drugs and biologicals to its residents. Specifically, a resident's multiple sclerosis medication was not available for administration, another resident's Clonidine, Hydralazine, and Ferrous Fumarate were documented as not available for administration, and a third resident's potassium chloride, topiramate, Myrbetriq, and duloxetine were documented as not available for administration. Resident identifiers: 6, 29, and 39.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and record review, for 1 of 36 sampled residents, the facility did not ensure that all alleged violations involving abuse and neglect were reported to the State Survey Agency (SSA). Specifically, the facility waited 5 days to report an allegation of abuse or neglect to the SSA, after a resident sustained a fall which resulted in a fracture. Resident identifier: 76.
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on observation, interview and record review, for 1 of 36 sampled residents, the facility did not provide appropriate treatments and services to maintain or improve his or her ability to carry out the activities of daily living, which included hygiene and bathing. Specifically, a resident was not provided showers and was observed to have a body odor. Resident identifier: 57.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, and record review, for 1 of 36 sampled residents, the facility did not ensure each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a resident with decreased sensation in her feet utilized hot packs heated in the microwave and staff were not able to determine the temperature prior to application. Resident identifier: 29.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on interview and record review it was determined that the facility did not ensure that residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, for 1 out of 36 sampled residents, the facility did not conduct a post dialysis assessment after each dialysis session. Resident identifier: 6.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on interview and record review, the facility did not ensure that the resident's drug regimen was free from any unnecessary drugs. An unnecessary drug was any drug used in excessive dose; for excessive duration; without adequate monitoring; without adequate indications for use; in the presence of adverse consequences; or any combination of the above. Specifically, for 2 out of 36 sampled residents, a resident had medications that were not administered with no documentation of the reason for omission, and insulin was held when it should have been administered per the physician ordered parameters. Additionally, a resident was administered blood pressure medications without a documented blood pressure reading. Resident identifiers: 6 and 59.
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on interview and record review, the facility did not provide or obtain laboratory services to meet the needs of its residents. Specifically, a resident that had their complete blood count (CBC) and urinalysis (UA) cancelled did not have those labs redrawn. Resident identifier: 39.
- D
Keep complete, dated laboratory records in the resident's record.
Inspectors wroteBased on interview and record review it was determined the facility did not file in the resident's clinical record laboratory reports that were dated and contain the name and address of the testing laboratory. Specifically, for 2 out of 36 sampled residents, the facility did not file the resident's laboratory results in their medical records. Resident identifiers: 6, and 9.
- D
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
Inspectors wroteBased on interview and record review it was determined that the facility did not ensure that radiology and diagnostic services were obtained to meet the needs of its residents. Specifically, for 1 of 36 sampled residents, the facility did obtain an x-ray of the right knee when ordered by the physician. Resident identifier: 9.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, for 2 of 36 sampled residents, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, hand hygiene was not completed during a dressing change and the wound bed was cleaned with multiple cross swipes with the same gauze pad. Additionally, medication was placed back into a blister pack after a resident refused it. Resident identifiers: 68 and 59.
March 13, 2025Complaint inspection · 2 citations
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, it was determined that the facility did not ensure, for 1 of 17 sampled residents, that residents received treatment and care in accordance with professional standards of practice. Specifically, the facility did not conduct wound care orders at prescribed by the physician. Resident identifier: 2. Findings Include: 1. Resident 2 was admitted to the facility on [DATE] following surgical repair of a fractured ankle. On March 18, 2025, the surveyor completed a review of Resident 2's medical record and the following entries were observed: Resident 2 had a wound care order that started on October 24, 2024 and was discontinued on November 1, 2024. The order had instructions to complete wound care to the right ankle on Mondays, Wednesdays, and Fridays. [...]
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on interview and record review, the facility did not ensure residents were free of significant medication errors. Specifically, for 1 of 17 sampled residents, multiple doses of medications, including antibiotics and insulin, were not administered as ordered by the physician. Resident identifier: 9.
March 29, 2024Standard inspection, Complaint inspection · 6 citations
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observations, interviews, record reviews, and facility policy review, the facility failed to protect resident personal health information (PHI) for 1 (Resident #55) of 1 sampled resident reviewed for privacy and 1 (Resident #46) of 4 sampled residents reviewed for dignity.
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on interview and facility document and policy review, the facility failed to conduct a criminal background check for 1 (Certified Nursing Assistant [CNA] #3) of 6 nursing department staff prior to employment at the facility.
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, interviews, record review, and facility document and policy review, the facility failed to provide supervision to prevent accidents related to elopement for 2 (Resident #59 and Resident #38) of 3 residents reviewed for elopement. Specifically, Resident #59 eloped from the facility on 02/24/2024 and was pushing their wheelchair when it was hit by a car. It was determined the facility's noncompliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25 (Quality of Care) at a scope and severity of J. The IJ began on 02/24/2024 at approximately 8:00 PM when Resident #59 eloped from the facility. [...]
- E
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Inspectors wroteBased on interviews, facility document review, and facility policy review, the facility failed to ensure 4 (Certified Nursing Assistant [CNA] #3, CNA #13, Nursing Assistant [NA] #26, and Licensed Practical Nurse [LPN] #27) of 6 sampled employees were provided mandatory training related to dementia management and resident abuse prevention.
- D
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on record review, interviews, and facility document and policy review, the facility failed to adequately address a grievance filed by a family member of 1 (Resident #328) of 1 sampled resident reviewed for neglect. Specifically, Resident #328's family member filed a grievance related to finding the resident lying in bowel movement and urine on the morning of 10/16/2023, and the facility was unable to provide documentation of the steps taken to investigate the concern or information regarding whether the facility was able to confirm the concern.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interviews, record reviews, and facility policy review, the facility failed to protect the residents' right to be free from physical abuse by a resident (Resident #228) for 2 (Resident #48 and Resident #42) of 5 sampled residents reviewed for abuse.
January 13, 2022Standard inspection · 5 citations
- G
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observation, interview, and record the review it was determined the facility did not ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, for 1 out of 30 sampled residents, a resident that had a fall and complained of pain was not provided pain medication for 11 days. Resident identifier: 51.
- E
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wrote3. Resident 17 was admitted to the facility on [DATE] with diagnoses which included but not limited to dysphagia following cerebral infarction, encephalopathy, dysphagia, mood disorder due to known physiological condition, cognitive communication deficit, pain, type 2 diabetes mellitus, essential hypertension, and acute respiratory failure with hypoxia. Resident 17's medical record was reviewed on 1/13/22. Resident 17's drug regimen was not reviewed by the pharmacist for irregularities in September 2021 and October 2021. 4. Resident 25 was admitted to the facility on [DATE] with diagnoses which included but not limited to metabolic encephalopathy, type 2 diabetes mellitus, anxiety disorder, restlessness and agitation, pain, and urinary tract infection. Resident 25's medical record was reviewed on 1/13/22. [...]
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and record review, it was determined the facility did not ensure residents who were unable to carry out activities of daily living, received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, for 1 out of 30 sampled residents, a resident did not receive the feeding assistance she needed at meal time. Resident identifier: 68.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, and record review it was determined the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, for 1 out of 30 sampled residents, a resident who had a fall and complained of pain was not provided a computed tomography (CT) scan timely to rule out a fracture. Resident identifier: 51.
- D
Provide or obtain dental services for each resident.
Inspectors wroteBased on interview and record review, it was determined the facility did not assist residents in obtaining routine and 24-hour emergency dental services. Specifically, for 1 out of 30 sampled residents, the facility did not follow-up with dental care when a resident continually complained of severe tooth pain, needing an x-ray, and dental extractions. Resident identifier: 60.
Fire safety inspections
16 fire safety citations on file: 2 on June 4, 2026, 10 on March 29, 2024, 4 on January 13, 2022.
Every fire safety citation16 citations
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 4, 2026 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · June 4, 2026 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · March 29, 2024 · Corrected (the home has a date of correction)
- F
Have restrictions on the use of portable space heaters.
K 781 · March 29, 2024 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · March 29, 2024 · Corrected (the home has a date of correction)
- D
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · March 29, 2024 · Corrected (the home has a date of correction)
- D
Meet other general requirements.
K 100 · March 29, 2024 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · March 29, 2024 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 29, 2024 · Corrected (the home has a date of correction)
- D
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · March 29, 2024 · Corrected (the home has a date of correction)
- D
Have simulated fire drills held at unexpected times.
K 712 · March 29, 2024 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · March 29, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 13, 2022 · Corrected (the home has a date of correction)
- D
Meet other general requirements.
K 200 · January 13, 2022 · Corrected (the home has a date of correction)
- D
Have simulated fire drills held at unexpected times.
K 712 · January 13, 2022 · Corrected (the home has a date of correction)
- D
Meet requirements for the use and maintenance of medical gas equipment.
K 922 · January 13, 2022 · Corrected (the home has a date of correction)